Ambulance Services and Records Requests
In case of an emergency call 911
Request for Records
To request NON-MEDICAL records complete the records request form below and e-mail it to fire@gjcity.org.
To request MEDICAL records call Wittman at 1-800-906-6552
| Office Address: | 625 Ute Avenue, Grand Junction, CO 81501 |
| Fax: | 970-549-5840 |
| Non-Emergency Ambulance Dispatch: | 970-242-6707 |
| Sheldon Kier - Medical Services Chief | sheldonk@gjcity.org |
| Billing Questions - Wittman Enterprises | 1-800-906-6552 |
Non-Emergency Transport Forms
- Advanced Beneficiary Notice (ABN)
- Hospice Payment Authorization Request
- Medicaid Authorization
- Patient/Guardian Consent to Release of Records
- Physician Certification Statement (PCS) for Medical Necessity
- Release of Medical Information for Billing Purposes
Needed Non-Emergency Transport Request Forms
- Non-Emergency Ambulance Transport Folder
- Physician’s Certification Statement (PCS) for Medical Necessity
- Patient Face Sheet
- Patient Medication List
- DNR Order (if patient has one)
Other Forms
Non-Emergency Ambulance Dispatch: 970-242-6707
* In case of an emergency call 911
